GU Flashcards
hematuria definition
> 3 RBC/HPF
- gross: more nonglomerular
- microscopic: more likely glomerular
causes of hematuria…
TITS:
- trauma (foley, blunt, exercise, FB)
- Infection / inflam - UTI #1 cause in adults!! glomerulonephritis, AIN, Goodpasture, IgA nephropathy, heoch-shoelien, wegener
- Tumor: GROSS PAINLESS HEMATUREIA IS BLADDER / KIDNEY CANCER UNTIL PROVEN OTHERWISE!!
- Stones - hypercalciuria
other: alport syndrome, RTA, heme d/o, meds (cyclosporine, aminoglycosides, analgesics) BPH
initial tests for workup…
Urine dipstick and U/A w/ microscopy and examine urine sediment and culture to r/o UTI. cytology w/ malignancy RF
RF for bladder malignancy
> 50 y/o, male, smoking, occupational exposure to chem/dyes, painless gross hematuria
diagnostic tests for GU system…
image (US/IVP/CT w/ and w/o contrast) upper (kidneys and ureters) and scope lower w/ cystoscopy unless infection present!
hematuria w/ no RBC found on mrico…
do dipstick..if positive for heme: mygolobin (clear plasma) or hemoglobin (red) or d/t food (beets) or meds
dark cola urine w/ elevated BP, edema w/ proteinuria w/ RBC casts and dysmorphic RBC on micro…
GLOMERULAR! usually glomerulonephritis
think about post-streptococcal GN w sore throat and skin infection 1-2 weeks prior or bergers dz (IgA nephroaphty) w/ 1-2 days of runny nose, sore throat and cough
w/ pyruia present + burning / dysuria on micro…
send for culture and tx for UTI
hematuria + hemoptysis
goodpastures! check for anca and antibodies to collagen
male w/ hematuria + deafness…
alport syndrome!
kid w/ recent viral infection, abdominal pain, arthralgais and purpura…
henoch-shoelein purpra
hematuria + little proteinuria micro and clots…
extraglomerular! check imaging for renal dz (CT) or bladder (cystoscopy)
UTI bugs
1 ecoli
90% d/t e coli, staph saprophyticus, enterococcus
-noninfectious: look for radiation, cyclophosphadmide
UTI - at risk populations
- diabetics (at risk of UPPER), renal failure
- immunocompromised
- spinal cord injury
- obstruction - neurogenic bladder, reflux,
- uncirc males
asymptomatic bacteriuria
2 successive positive cultures !(>10x5e)
ONLY TREAT IF PREGO OR BEFORE UROLOGIC PROCEDURE!
**only need 1 in males!
sx
void symptoms: dysuria, urgency, frequency
hematuria
suprapubic tenderness
**no systemic / fever
diagnosis:
- dipstick - nitrites specific for gram neg; leuk esterase key for uti
- u/a: criteria
- bacteriuria >1 org/field
- pyruria more or equal to 10 leuk / miroliter!
- urine culture - used more in hospital or w/ recurrent, obstruction, diaphragm use, prolonged >7 days of symptoms, diabetic, 65 and older
complicated UTI
considered if:
- male
- diabetic
- immunocopromised
- prego,
- h/o pyelonephritis w/in last year
tx for uncomplicated UTI
- keflex 250-500 mg q 6 x 3 days
- macrobid 100 mg q 12 hr x 3 days
- bactrim (160/800) BID x 3 days
- can give pyridium for dysuria (turns pee orange)
- fosfomycin 3 g dose (not really used)
* *if recurrent w/in 2 weeks of treatment, treat another 2 weeks and get a culture!
prego UTI
- ampicillin
- amoxicillin
- augmentin
- cephalosporins
treat x 7 days
NO FQ
male UTI
fconsidered COMPLICATED 1. urologic workup 2. bactrim and FQ NO MACROBID AND NO BETA LACTAMS! treat for 7 days if no sx of prostatitis / pyelo!
when to consider prophylactic tx…
if 3 or more episodes in 1 year!
- *do urologic eval!!
1. bactrim (40/200)
2. macrobid
3. keflex - single dose at bedtime or after intercourse!
pyelonephritis!
infection of upper urinary tract d/t reflux from bladder
E coli most common bug
uncomplicated if it remains at renal pyelocalyceal-medullary region (complicated can affect any part of kidney)
pyelo complications…
- urosepsis
- emphysematous - gas producing bacteria more in diabetics
- chronic leading to scarring - often in patients w/ renal disease
pyelo sx
cystitis + systemic - fever, chills, tachycardia, flank pain, CVA tenderness
pyelo diagnosis
- u/a -LEUKOCYTE CASTS, pyuria, bacteriuria
- urine cultures - done in ALL
- blood culture - do if ill-appearing or IN HOSPITALIZED
- cbc, renal function (if impaired reversible)
- do imaging if refractory to treatment
pyelo tx -outpatient
NO MACROBID!
oral: bactrim or FQ (cipro, levo) x 10-14 days
- repeat urine culture in 2-4 days after cessation of tx
- if no reponse, get imaging (CT or ultrasound)
pyelo tx - inpatient
- admit if really sick / old / prego / cannot tolerate orals / sig comorbidities / urosepsis
1. IV ampicillin and gentamicin or cipro - *continue IV until afebrile x 24 hrs, then oral to for 14-21 day course
- once changed to oral:
2. cipro 750 BID x 21 d
3. bactrim x 21 days - *w/ urosepsis, treat w/ IV 2-3 weeks
recurrent pyelo
- if same organism, treat x 6 weeks
- if new organism, tx x 2 weeks
ATN
85% of intrinsic AKI - two major types
- ischemic: prolonged decreased RBF and GFR kills tubular cells! i.e. hypotension, dehydration, shock, sepsis
- nephrotoxic: meds -
- aminoglycosides -often 5-10 days after onset (last in system x 1 mo)
- cyclosporine (dose dependent - should improve w/ dec dose or stopping med) - NSAIDS
- vanco, acyclovir, amphotericin B (toxic at 2-3 g dose and up) - ***RADIOCONTRAST! #3 cause of AKI! give 0.9% NS 1L over 10-12 hr before and after procedure for protection! can give n-acetylcysteine 600 mg every 12 hours twice before and after or sodium bicarb
- avoid nephrotoxic meds day before and after dye! - endogenous: myoglobin w/ rhabdo (check CK - most over 16,000 tx w/ volume repletion!) and hemoglobin (hemolysis / transfusion reaction - tx underlying and hydrate!)
- hyperuricemia secondary to chemo!
- bence jones proteins w/ MM
- aminoglycosides -often 5-10 days after onset (last in system x 1 mo)
ATN labs
- hyperkalemia and hyperphos
- BUN:crt 2-3% or >20 meq/l
- GRANULAR MUDDY CASTS!!! RENAL TUBULAR EPITHELIAL CELLS!
ATN treatment
- fluids!! volume repletion and stop all nephrotoxic agents!
- may use loops furosemide w/ chlorthiazide or metolazone to increase urine outpu
- can use furosemide drip to avoid toxic doses of loops (hearing loss and cerebellar dysfunction)
- w/ rhabdo - dont treat hypocalcemia unless symptomatic!
- avoid mag-containing antacids / laxatives - kidney hangs onto potassium, phos, H+, magnesium w/ damage!
3 phases of ATN
- injury
2. oliguric phse: 10-14 days w/ urine output 500 ml/d - GFR increases, BUN:crt begin to fall!
AIN patho / causes
interstitial inflammation, most commonly due to ALLERGIC (THINK EOS!) TO NEW MEDICATION!!! (PCN, SULFA, CEPH, diuretics, PPI!!! VERA SAID #1 CAUSE, ALLOPURINOL, RIFAMPIN)
- infection - esp kids - STREP! legionella
- AI and collagen dz…sarcoid..SLE, sjogrens
AIN classic findings…
FEVER, RASH, PYURIA, EOS IN URINE!!!
**look for hx of NEW MEDICATION or RECENT ILLNESS! with signs of AKI
AIN diagnosis
clinical w/ new exposure and has: fever, AKI, rash, eosinophilia!
-get u/a (may have protein /hematuria)
AIN tx
remove agent - often reverses
w/o improvement, may need steroid (prednisone 60 mg/d x 1-2 weeks or iv methylprednisone x 1-4 d)
acute glomerulonephritis…
uncommon cause of AKI - inflammatory glomerular lesions w/ proteinuria (<3 g/d) hematuria and RED CELL CASTS W/ DYSMORPHIC RBC!!!
glomerulonephritis causes…
- immune
- *most common: poststreptococcal GN
- IgA nephropathy (Berger disease)
- anti-gbm / good pasture
- vasculitis, collagen dz, SLE, polyarteritis nedosa, henoch shonelein
GN pres…
- *boy w/ history of strep infection (sore throat 1-2 weeks prior or skin infection 2-4 weeks prior) w/ new onset periorbital and scrotal edema w/ dark urine
- dependent edema and HTN
GN labs..
- increasing BUN:crt
- U/A dipstick: hematuria, mod proteinuria <3g/d, red cells, red cell casts and white cells
whats most specific for GN on dipstick?
RED CELL CASTS!!!
extra tests to get once Dx GN…
completment levels, ASO titer, anti-GBM, ana, anaca, hepatitis, blood cultures, cryoglobulins
-renal u/s
nephrotic syndrome…
keys: lose protein d/t increased permeability!
1. urine protein >3.5 g/ 24 hr
2. hypoabluminemia
3. hyperlipidemia - get increased LDL and VLDL w/ increase in albumin synthesis
4. edema
- hypercoaguable d/t loss of anticoags in urine
- increased infection d/t increased loss of immunoglobulins in urine
testing w/ nephrotic…
- dipstick - w/ positive get u/a
- u/a - RBC cast indicate GN
- WBC cast = pyelo or interstitial nephritis
- fatty cast = NEPHROTIC!
* w/ positive u/a get 24 hour urine collection! - test for microablumin - if positive dipstick, get radioimmunoassay
most common causes of nephrotic…
adults: membranous glomerulonephritis
kids: minimal change disease
nephritic sydrome keys…
inflammation of glomeruli w/:
- hematuria
- AKI - azotemia, oliguira
- HTN
- edema
- may have mild proteinuria
nephritic causes…
1 post-streptococcal!
glomerular vs tubular disease..
Glomerular is more chronic, causes nephrotic syndrome, requires biopsy and tx w/ steroids
Tubular more acute, d/t toxins, no biopsy no steroids!
